Archive for the ‘Changing the System’ Category

Michael Galinsky, a director of and a principal subject in a documentary about chronic pain titled All The Rage has written a wonderful essay (1) on the process of physicians changing their practice (or not) in response to research data. Any one interested in how treatment of chronic pain and other symptoms linked to psychophysiologic disorders will evolve (or not) in coming years will find it clearly written and edifying.

A major change in the financial incentives for care of Psychophysiologic Disorders (PPD) has just occurred in the United States (1). The case for integrating both medical and mental health care into primary care has always been compelling. Now, in 2017, the U.S. Medicare/Medicaid system has decided it will pay for a form of care that is strongly aligned with this concept (more on that below).

Prescription opiate medication for chronic pain is a treatment whose time is ending. To quote Dr. Tom Frieden, director of the Center for Disease Control (CDC), for most pain patients the benefits of opiate painkillers are “unproven and transient” and they can be “just as addictive as heroin.” In addition, annually since 1999, ten thousand people have died from overdoses of prescription painkillers. The pain management community has concluded that, apart from people with cancer pain or those at the end of life, opiate painkillers have become a public health crisis. The CDC now recommends against using them for most non-cancer patients.

Acceptance by the health care profession that Psychophysiologic Disorders (PPD) can be successfully diagnosed and treated will depend on completion of at least two randomized controlled trials (RCT). The RCT is the gold standard method for documenting that a new form of treatment is superior to a placebo. Only when a treatment passes this test and that passing is then confirmed by at least one additional RCT will clinicians consider making the effort to apply it to their patients.

Among physicians with a humanistic soul, perhaps no quotation is more fondly remembered than one from Dr Francis Peabody. He was born in 1881 to a prominent New England family, trained at Harvard and Massachusetts General Hospital and was the first director of the Thorndike Laboratory at Boston City Hospital. Tragically, he died of sarcoma at age 46.

Psychophysiologic Disorders (PPD) consist of pain or other physical symptoms that are partly or completely relieved when underlying psychosocial issues are uncovered and treated. The process that produces this form of illness is an area of active investigation.

A colleague asked how I would screen for Adverse Childhood Experiences (ACEs) in primary care patients with unexplained illness, chronic pain or functional syndromes such as irritable bowel or fibromyalgia. (A blog of mine describing ACEs is here with an important web site here). Here is my answer:

The medical profession has been aware that psychosocial issues can lead to physical symptoms at least since the days of Hippocrates about 2500 years ago. Yet diagnosis and treatment for the pain and other symptoms lag far behind nearly every other form of illness. In thinking about this I began to recognize several challenges to improving the quality of care for this condition.

The last post briefly described a few psychotherapy concepts employed by students of Carl Jung. I wrote this to suggest the diversity of the scores of theoretical models currently used to treat clients. Why are there so many? The answer seems to be that they are all about equally effective when compared in trials so none has become dominant. Why are they so similar in their outcomes? The best explanation is that the theory behind a particular psychotherapeutic approach is one of the least important of several factors that determine how much a client benefits from treatment. What are these other components? In order of importance they are factors connected to: (more…)